Provider Demographics
NPI:1407806797
Name:HASSOUN, HEITHAM (MD)
Entity Type:Individual
Prefix:
First Name:HEITHAM
Middle Name:
Last Name:HASSOUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 512717
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0717
Mailing Address - Country:US
Mailing Address - Phone:424-315-4508
Mailing Address - Fax:
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:424-315-4508
Practice Address - Fax:310-423-0246
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1604172086S0129X
TXL08172086S0129X
MDD635272086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408464100Medicaid
TX8BZ860OtherBLUE CROSS BLUE SHIELD
TX141192802Medicaid
TX141192803Medicaid
MDKR72M205Medicare ID - Type Unspecified
TX8L14629Medicare PIN
TX8L23943Medicare PIN
MDH31400Medicare UPIN
TXTXB145129Medicare PIN